Provider Demographics
NPI:1821228529
Name:MELLENCAMP, LYNN E (CN10784-NP)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:E
Last Name:MELLENCAMP
Suffix:
Gender:F
Credentials:CN10784-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6056 TENNYSON DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-6428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9403 KENWOOD RD
Practice Address - Street 2:SUITE B-100
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-6895
Practice Address - Country:US
Practice Address - Phone:513-891-8045
Practice Address - Fax:513-891-8110
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.10784-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH485400Medicare PIN